Luigi De Vitis

Optical coherence tomography angiography of myopic choroidal neovascularisation

Background/aims To describe the morphological features of choroidal neovascularisation (CNV) and to report the ability of optical coherence tomography angiography (OCT-A) to detect the presence of myopic CNV by means of this new technique. Methods Myopic CNV cases were individuated from a pool of patients with pathological myopia consecutively presenting between October 2015 and March 2016. OCT-A images were assessed for classification of morphological features, and to estimate sensitivity and specificity. Results Thirty-six eyes of 28 consecutive patients with myopic CNV were included. In 4 out of 36 eyes it was not possible to classify the CNV ‘shape’, ‘core’, ‘margin’ and ‘appearance’ because the vascular network was not clearly visualised due to the poor quality of the examination. CNV shape on OCT-A was rated as circular in 9 eyes and irregular in 23 eyes. CNV core was visible in 11 eyes. CNV margin was considered as well defined in 16 eyes and poorly defined in 16 eyes. CNV appearance showed an ‘interlacing’ aspect in 16 eyes and a ‘tangled’ aspect in the other 16 eyes. A total of 11 CNVs were defined as active, 9 of which (81.8%) were interlacing, while a total of 21 were inactive, 14 of which (66.7%) were tangled. OCT-A sensitivity turned out to be 90.48% and specificity was 93.75%. Conclusions We describe the OCT-A features of myopic CNV secondary to pathological myopia and demonstrate its high sensitivity and specificity for neovascular detection. Qualitative evaluation of OCT-A characteristics may allow one to recognise different patterns, possibly corresponding to different degrees of neovascular activity.

Choroid morphometric analysis in non-neovascular age-related macular degeneration by means of optical coherence tomography angiography

Aims To describe the vascular changes in patients affected by non-neovascular age-related macular degeneration (AMD), featuring reticular pseudodrusen (RPD), drusen, or both RPD and drusen by means of optical coherence tomography angiography (OCT-A). Methods Cross-sectional observational case series. Patients with non-neovascular AMD presenting at the Medical Retina Service of the Department of Ophthalmology, University Vita-Salute San Raffaele in Milan were recruited. Patients underwent best-corrected visual acuity, biomicroscopy, infrared reflectance, short-wavelength fundus autofluorescence and OCT-A (AngioPlex, CIRRUS HD-OCT 5000, Carl Zeiss Meditech, Dublin, USA). Main outcome was quantification of vessel density, stromal tissue, and vascular/stromal (V/S) ratio at the choriocapillaris (CC), the Sattler and Hallers and the whole choroid layers among different groups of patients with non-neovascular AMD by means of binarised OCT-A scans. Results 45 eyes of 34 patients were enrolled (15 eyes of 11 patients with RPD, group 1; 15 eyes of 11 patients with drusen, group 2; 15 eyes of 12 patients with mixed phenotype, group 3). The CC, the Sattler and Hallers and the whole choroid vessel density were reduced in all groups of patients (p=0.023, p=0.007 and p=0.011 in group 1, group 2 and group 3 for the CC; p=0.021, p=0.037 and p=0.043 in group 1, group 2 and group 3 for the Sattler and Hallers density; p=0.016, p=0.002 and p<0.001 in group 1, group 2 and group 3 for the choroidal density), with significantly lower V/S ratios compared with healthy controls. Conclusions Patients with non-neovascular AMD show significant choroidal vascular depletion and fibrotic replacement, suggesting a possible role in the pathogenesis and progression of the disease.

Optical coherence tomography angiography findings in laser maculopathy

Purpose Handheld laser pointer thermal injury affects primarily the retinal pigment epithelium (RPE). However, so far no study has reported on the possible effects of laser pointers in the deeper layers, beneath the RPE. Here, we describe the spectral-domain optical coherence tomography angiography findings in the choriocapillaris of a patient with laser maculopathy. Methods A 13-year-old boy presented to our department with decreased vision in the left eye 12 hours after having stared at the beam of a laser pointer. Results Structural optical coherence tomography (OCT) showed 2 focal hyperreflective columns at the fovea extending from the RPE, involving all outer retinal layers, and terminating at the outer plexiform layer. The patient also underwent OCT angiography (OCT-A), which in the choriocapillary segmentation revealed 2 hypointense lesions in correspondence of the focal hyperreflectivities detected on structural OCT. We hypothesize that the OCT-A findings could represent a rarefaction of the choriocapillaris. However, the choriocapillary OCT-A findings could also represent artifacts due to the overlaying hyperreflective lesions. Conclusions It is known that the RPE is primarily damaged by the laser injury. Our findings suggest that the thermal injury could involve also the choriocapillaris, and thus not limited to the RPE. Multimodal imaging in laser maculopathy including OCT-A may lead to a better comprehension of the pathogenesis of laser retinal damages.

Choroidal neovascularization and coincident perforating scleral vessels in pathologic myopia

Purpose To describe the coincidence of perforating scleral vessels and choroidal neovascularization (CNV) in pathologic myopia. Methods Medical records and multimodal imaging were reviewed from patients with CNV secondary to pathologic myopia who presented to the Medical Retina and Imaging Unit of San Raffaele Hospital in Milan between October 2015 and March 2016. Main outcomes were the prevalence of coincident perforating scleral vessels and overlying CNV and association between perforating scleral vessels and CNV position within the macula and neovascular activity. Results Forty-one eyes of 39 patients (6 male, 33 female, mean age 63.7 ± 14.1 years) with CNV secondary to pathologic myopia were included in the study. Scleral perforating vessels (average number of perforating vessels per eye 2.1 ± 1.0) were found in 29 out of 41 eyes (70.7%) at the site of CNV. There was no association between presence of perforating vessels and neovascular activity or CNV position. Conclusions Perforating scleral vessels are often coincident with myopic CNV. We hypothesize that scleral vessels located beneath myopic CNV can play a role in neovascular development.

Choroidal Round Hyporeflectivities in Geographic Atrophy.

Purpose In geographic atrophy (GA), choroidal vessels typically appear on structural optical coherence tomography (OCT) as hyperreflective round areas with highly reflective borders. We observed that some GA eyes show choroidal round hyporeflectivities with highly reflective borders beneath the atrophy, and futher investigated the charcteristcs by comparing structural OCT, indocyanine green angiography (ICGA) and OCT angiography (OCT-A). Methods Round hyporeflectivities were individuated from a pool of patients with GA secondary to non-neovascular age-related macular degeneration consecutively presenting between October 2015 and March 2016 at the Medical Retina & Imaging Unit of the University Vita-Salute San Raffaele. Patients underwent a complete ophthalmologic examination including ICGA, structural OCT and OCT-A. The correspondence between choroidal round hyporeflectivities beneath GA on structural OCT and ICGA and OCT-A imaging were analyzed. Results Fifty eyes of 26 consecutive patients (17 females and 9 males; mean age 76.8±6.2 years) with GA were included. Twenty-nine round hyporeflectivities have been found by OCT in choroidal layers in 21 eyes of 21 patients (42.0%; estimated prevalence of 57.7%). All 29 round hyporeflectivities showed constantly a hyperreflective border and a backscattering on structural OCT, and appeared as hypofluorescent in late phase ICGA and as dark foci with non detectable flow in the choroidal segmentation of OCT-A. Interestingly, the GA area was greater in eyes with compared to eyes without round hyporeflectivities (9.30±5.74 and 5.57±4.48mm2, respectively; p = 0.01). Conclusions Our results suggest that most round hyporeflectivities beneath GA may represent non-perfused or hypo-perfused choroidal vessels with non-detectable flow.

Laser photocoagulation as treatment of non-exudative age-related macular degeneration: state-of-the-art and future perspectives

PurposeTo give an updated review of laser approaches to non-exudative age-related macular degeneration (AMD).MethodsPubMed and Medline database searches were carried out using the terms “laser” and “photocoagulation” associated with “age-related macular degeneration”, and latest publications up to May 2017 have been reviewed. Moreover, the design of an ongoing single-center, non-randomized, phase I–II, pilot study, the PASCAL-GA trial, coordinated by F. Bandello, MD and G. Querques, MD from the IRCCS Ospedale San Raffaele, is described.ResultsEither standard or subthreshold laser strategies have been tried to induce regression of distinct phenotypes of AMD, as reticular pseudodrusen (RPD), nascent geographic atrophy (nGA), and drusen-associated geographic atrophy (DAGA), with heterogeneous results. The aim of the PASCAL-GA protocol is to assess if subthreshold laser can restore the retinal pigment epithelium function in eyes with RPD and nGA offering a protective effect against extensive GA.ConclusionsNew-generation medical and surgical approaches, including subthreshold laser photocoagulation, may have some success in downstaging AMD.

DualTrack Technology Improves Optical Coherence Tomography Angiography Image Quality

BACKGROUND AND OBJECTIVE To evaluate the effects of DualTrack Motion Correction Technology on the performance of AngioVue optical coherence tomography angiography (Optovue, Freemont, CA). PATIENTS AND METHODS Fifty subjects underwent two consecutive examinations with AngioVue. The operator inactivated the eye-tracking (ET) technology before the second examination. Two operators measured execution time, excluded low-quality images, and counted the number of motion artifacts per image. RESULTS The mean execution time was lower without ET in all the groups (P < .05), regardless of retinal diseases. Percentages of available images and low-quality images were 75.0% and 25.0%, respectively, with ET and 63.0% and 37.0%, respectively, without ET. Mean number of motion artifacts was significantly lower in images obtained using ET compared to images obtained without ET in all the groups (P < .0001), regardless of retinal diseases. CONCLUSION Although ET technology increases the mean execution time, the reduction of motion artifacts and the increase of high-quality images may represent a great advantage in clinical practice. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:918-926.].

Emerging Issues for Ultra-Wide Field Angiography

Fluorescein angiography (FA) is a useful test in patients affected by diabetic retinopathy (DR) to evaluate the blood-retinal barrier integrity and the presence of non-perfused areas, vascular leakage, microvascular abnormalities, and neovascularization. The peripheral retina is involved in most DR lesions, and, thus, its proper visualization is crucial for the screening, diagnosis, monitoring, treatment, and prognosis of DR. To expand the field of view, wide-field and ultra-wide-field imaging have been developed, allowing images up to 200° of retinal surface in one single photo. In this chapter, emerging issues concerning ultra-wide-field FA in DR are illustrated.

Mineralocorticoid receptor antagonists in the treatment of central serous chorioretinopathy

ABSTRACT Introduction: Central serous chorioretinopathy (CSC) is one of the most common causes of central vision loss that primarily affects young adults. CSC is a multifactorial condition in which corticosteroids typically worsen the disease; this led to hypothesize the involvement of the mineralcorticoid receptor in its pathogenesis (due to the similar affinity of corticosteroids and aldosterone to this receptor). Area covered: Here, we perform a comprehensive literature review of all articles published in the English language, indexed on Pubmed, on the subject of ‘Mineralocorticoid receptor antagonists in the treatment of CSC.’ From these articles, the most salient disputes are presented. Expert commentary: Due to the lack of large randomized, controlled trials with long-term follow-up clearly demonstrating the positive effects of these treatments for CSC, no specific recommendation for the management of this disease has been defined yet. Despite lack of evidence level 1, mineralocorticoid receptor antagonists may represent an attractive therapeutic option for CSC. This review helps to clarity the efficacy and side effects of these drugs that maybe play an important role in treatment of CSC.

Sudden Visual Loss after Cardiac Resynchronization Therapy Device Implantation

Purpose To report a case of sudden decrease in visual acuity possibly due to a cardiogenic embolism in a patient who underwent cardiac resynchronization therapy (CRT) device implantation. Methods A 62-year-old man with severe left ventricular systolic dysfunction and a left bundle branch block was referred to our department because of a sudden decrease in visual acuity. Nine days earlier, he had undergone cardiac transapical implantation of a CRT device, which was followed, 2 days later, by an inflammatory reaction. The patient underwent several general and ophthalmologic examinations, including multimodal imaging. Results At presentation, right eye (RE) best-corrected visual acuity (BCVA) was counting fingers and RE pupil was hyporeactive. Fundus examination revealed white-centered hemorrhagic dots suggestive of Roth spots. Fluorescein angiography showed delay in vascular perfusion during early stage, late hyperfluorescence of the macula and optic disk, and peripheral perivascular leakage. The first visual field test showed complete loss of vision RE and a normal left eye. Due to suspected giant cell arteritis, temporal artery biopsy was performed. Thirty minutes after the procedure, an ischemic stroke with right hemisyndrome and aphasia occurred. The RE BCVA worsened to hands motion. Four months later, RE BCVA did not improve, despite improvement in fluorescein angiography inflammatory sign. Conclusions We report a possible cardiogenic embolism secondary to undiagnosed infective endocarditis causing monocular visual loss after CRT device implantation. It remains unclear how the embolus caused severe functional damage without altering the retinal anatomical structure.